Provider Demographics
NPI:1033735089
Name:RICHMOND, TREVOR DANIEL (DMD)
Entity type:Individual
Prefix:DR
First Name:TREVOR
Middle Name:DANIEL
Last Name:RICHMOND
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7713 S STRANZ RD
Mailing Address - Street 2:
Mailing Address - City:MAPLETON
Mailing Address - State:IL
Mailing Address - Zip Code:61547-9412
Mailing Address - Country:US
Mailing Address - Phone:309-431-1512
Mailing Address - Fax:
Practice Address - Street 1:11825 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:DUNLAP
Practice Address - State:IL
Practice Address - Zip Code:61525-8842
Practice Address - Country:US
Practice Address - Phone:309-740-3901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-24
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021.0033281223P0300X
IL019.032728122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist